The purpose of the set of studies published in this issue of the
Journal of Health, Population and Nutrition is to examine long- and
short-term consequences of maternal complications for mothers and
newborns and to document the physical, social, psychological and
economic impacts of maternal ill-health and maternal and perinatal death
on women and others living in the family unit. This work reflects the
spirit of President Obama's Global Health Initiative that draws
special attention to women- and girl-centred approaches as central to
the advancement of health and development.

In the past, the documentation of the global estimates of
reductions in maternal mortality has not been matched by more in-depth
efforts to characterize and understand the continuing burden of maternal
complications, morbidity, and disability suffered by childbearing women
in developing countries. With the exception of recent more in-depth
studies in India, Burkina Faso, and Benin, the global understanding of
reduction in maternal mortality and morbidity is based upon the
estimates of the number and proportion of childbearing women who die
(1). By and large, the documentation of morbidities during or after the
intrapartum period has lacked specificity and precision to inform the
country and the programme managers on the incidence of immediate
disabilities and of longer-term consequences for women, their families,
and their communities. The grand syntheses are limited by available
evidence--meagre compared to the magnitude and wide array of potential
consequences of maternal ill-health on individuals and society (2,3).

This series of papers presents, for the first time in two
geographic areas, a comprehensive snapshot of the short- and long-term
consequences of acute maternal morbidity. The icddr,b surveillance site
in Matlab, Bangladesh, has a unique set of records of the reproductive
health of individual women that provide data accumulated for decades.
This was selected as an ideal site to draw upon the database to examine
retrospectively long-term and prospectively selected short-term
consequences of maternal ill-health. This is the first attempt to obtain
greater precision on the consequences of maternal ill-health, using a
robust methodology and an extensive dataset, with added qualitative
studies and postpartum physical examinations of women following
childbirth. In addition, we have included a study that provides
contrasting and additional information from Action Research and Training
for Health in rural Rajasthan, India.

The Bangladesh study found that for every maternal death, there are
about 40 severe/less-severe complications and over 160 postpartum
morbidities/disabilities. These numbers are far higher than previous
estimates of 20 women with complications and 40 with postpartum
morbidities/disabilities for every maternal death (4).

In undertaking this work, it became apparent that even with the
provision of free services and the capability to assess and manage the
physical conditions of postpartum women, it is extremely hard to ensure
that all who need services obtain them. As a result, it appears from the
data that women from higher-income families have a higher burden of
morbidity than poorer women. In reality, the poorer women remain outside
the available services for various reasons, and their experiences are
not reflected in the documentation.

Immediate consequences of maternal complications

In Matlab, about 10% of women have a severe or less-severe maternal
complication during the intra-partum period (Huda et al.). While severe
dystocia is the most common complication, women are most likely to die
of haemorrhage. Most women who died sought care from public or private
facilities; about 25% died at home.

The Bangladesh study found that physical complications following
delivery are common--over 40% of women, including those with acute
maternal complications during the intrapartum period and those with
normal vaginal births, suffered from some postpartum morbidity--but most
are relatively mild, including first-degree uterine prolapse,
haemorrhoids, and hypertension (Ferdous et al.).

'Consequences of the consequences'

As part of this series of studies, a paper previously published (5)
showed a substantial effect of the death of the mother on the survival
of her children. "The cumulative probability of survival up to age
10 years was 24% in children whose mothers died before their tenth
birthday compared to 89% in those whose mothers remained alive. The
greatest effect was noted in children aged 2-5 months, whose mothers had
died. The effect of the father's death on cumulative probability of
survival of the child up to 10 years of age was negligible" (5).

An important finding is that infant mortality is approximately
eight times higher for those infants whose mothers died than if the
mother survived (5). This finding has enormous implications for our care
for these infants who are now maternal orphans.

Beyond survival, the studies describe a vast array of sequelae
following obstetric complications--some very serious and some less
prevalent or more serious than we had anticipated. While there was a
small effect of maternal anaemia on young children's language
ability, there were often substantial consequences for women due to
different morbidities (Hamadani et al). Not surprisingly, there is a
vast array of quality of life issues. For example, beyond the physical
results of fistula, uterine prolapse, and incontinence, there is
documentation of profound effects on women's daily activities. And,
in the case of a perinatal death, women may be sequestered for years and
be unable to even carry out religious rituals that they consider
fundamental to their spiritual well-being (Khan et al.). The
consequences of a perinatal death on the mother include postpartum
depression as well as emotional violence and controlling behaviour by
the family and the community.

The study finds that there is a significant association between
Bangladeshi women who report negative experiences with their childbirth
and postpartum depression (Gausia et al.). Furthermore, women with
conditions of chronic maternal morbidities, such as uterine prolapse,
sometimes experience khota (insult) whereby they are ridiculed by
neighbours and in-laws for jeopardizing the marriage through not meeting
the sexual needs of the husband or not carrying out household
responsibilities. Women described physical and sexual violence in
response to not meeting husbands' demands. The subordinate role of
women subjects them to an array of hardships and injustices that result
from their chronic morbidities and disabilities (Khan et al.).

This research has elicited considerable detail about the economic
consequences of maternal morbidity, which are the highest within the six
weeks after birth and decline substantially by six months (Hoque et
al.). Faced with maternal complications, families take loans and, to a
lesser extent, sell assets to pay for healthcare. By interviewing
cohorts of families, the study found that, even among the poorest
households, there was unexpected resiliency to the economic shock of the
cost of paying for obstetric emergencies. Families invest in their women
in Bangladesh and will bypass lower-level facilities perceived to have
lower quality to seek care for obstetric emergencies. These findings
differ from findings in other country settings and point to the need for
more robust methodologies and more comparable studies in other settings
to increase the understanding of various coping strategies and both
economic and non-economic consequences--beyond the actual financial
debt.

Evolving context in Bangladesh

We recognize that the environment in Bangladesh is highly dynamic.
Maternal mortality declined by 40% to 194/100,000 livebirths between
2001 and 2010 (6). Death from maternal causes now follows cancers and
circulatory diseases as the major causes of death of Bangladeshi women
of reproductive age. This progress appears to result from improved
awareness of the need for care during emergencies and overall increased
care-seeking for delivery, higher levels of maternal education, better
economic conditions, and reduction in fertility--the total fertility
rate has fallen to 2.5 (6). As a result, we are not finding the extent
of long-term injury apparently suffered by women in other settings,
particularly in settings where maternal mortality is higher. With the
lowering of fertility and maternal mortality and the increased use of
services, there is the prospect that more complications leading to
disabilities can be prevented.

Comparing India and Bangladesh findings

The study in rural Rajasthan, India, published in this special
issue, focused on the physical problems of postpartum women (Iyengar).
As in Bangladesh (6), delivery-care in Rajasthan is rapidly moving to
the health facility. Unlike in Bangladesh, moderate and severe anaemia
is the most common maternal morbidity, followed by puerperal infections.
Both the studies raise the concern that the postpartum period is one
with high risk for women.

Given the variation in the pattern of postpartum maternal
morbidities and disabilities in the Bangladesh and India studies,
additional research in other country contexts is needed to quantify the
changes in the burden of disease and to add to our knowledge concerning
the many maternal morbidities and disabilities not now included in the
calculation of disability-adjusted life-years.

Recommendations

The results of this wide-ranging set of studies make the case for
galvanizing attention in a Call to Action to highlight the importance of
postpartum and postnatal care that goes beyond the standard 4-6-week
period. This will involve communications to women and their families
about the importance of postpartum care and assessing the risk and
actual occurrence of complications and responding effectively to them by
healthcare providers. It will also mean following up women who have had
a normal vaginal delivery, especially those who remained at home. The
children of mothers who died and the mothers of perinates who died
require very special attention because of their increased vulnerability.

Screening is called for several times following the birth, whether
inside or outside a healthcare facility since problems may emerge or be
recognized at different times in the postpartum period. All women need
to be screened for physical postpartum problems, including anaemia,
infection, incontinence, uterine prolapse, and obstetric fistula, and be
managed, along with the provision of family planning and counselling for
taking care of themselves and their babies. Women also need to be
screened for postpartum depression and experience of emotional, physical
and sexual violence. There are obvious possibilities for making this
happen--first, at the time of hospital discharge and at the
'usual' 4-6-week postpartum check-up, and perhaps at
immunization points for the child. We need to assess and re-assess. The
findings of this study in Matlab, Bangladesh, point to the need for
follow-up, including outreach to the community, especially when the
birth has occurred at home, and particularly to follow-up on the
survivors of a maternal or perinatal death. These mothers and babies are
highly vulnerable and require special attention.

Second, beyond screening, we need improvements in the healthcare
system to build individual expertise and organizational capacity to
respond to and effectively treat problems ranging from severe uterine
prolapse and fistula, requiring specialized surgery, to depression and
violence, requiring specialized counselling and intervention.

Third, social protection is vital for the most vulnerable. Although
this study suggests innovative coping and care-seeking strategies by
Bangladeshi families, an effective health system is needed to provide
accessible preventive and lifesaving care, particularly for the most
economically- and socially-vulnerable populations.

Finally, since societal customs and expectations set the stage for
perpetrating and condoning the devastating emotional, physical and
sexual abuse that women experience as a result of chronic morbidities
and disabilities, these problems will not all be solved by healthcare
providers or health services improvement alone. We must spotlight the
fundamental issues of status and human rights of women for which the
answers will be found in education, employment, and empowerment of
women, in partnership with men, to improve the well-being of families.

ACKNOWLEDGEMENTS

The opinions expressed in this paper are those of the authors and
not necessarily of the United States Agency for International
Development where they work.

(2.) National Research Council. The consequences of maternal
morbidity and maternal mortality: report of a workshop. Committee on
Population. In: Reid HE, Koblinsky MA, Mosley WH, editors. Commission on
behavioral and social sciences and education. Washington, DC: National
Academy Press, 2000.

(3.) Better off dead? A report on maternal morbidity from the UK
All Party Parliamentary Group on Population, Development and
Reproductive Health. London: UK All Party Parliamentary Group on
Population, Development and Reproductive Health, 2009.